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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />riniculAl <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Developprr7ent Title, Cha ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />5,,_+4 50/�,'.A p �,�,.,� / /. Assessors <br />WELL Location _T Iti s r S Cross StreetGrv3� t�� �. �. - City 54 cK ko- Zip �2IQ Parcel# /Vy <br />PROPERTY ��,��pp //�//� / <br />OwnerCc 1;4r^; c i n��� o'F P' d0dre i��, o, Box ZaY City 5Iac,lcF _ Zip 7.52o l Phone# <br />C-57 Contractor(cng ddress 75-0 E/,%,c /P".{ City,�O �cl..- Zip `/J Lic#Y�$/ $' Phone# 925-313-5froo <br />Consultant Sub Cntrt/-Ct'-bri4. 4�V. 1-0r~_ddress Z'76 Per 1., i CitysonoMc� Lic#C(/,e1 Phone# 707-9./33-2361 <br />GIS Coordinates: X /AiA I Y AZ A , Township �� Range 6 L Section G 9 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />SWELL # M L/ -tat ML!-IZ 0 PRESSURE GROUT <br />0 *Other � GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 'HOLLOW STEM DIA. OF BOREHOLE5 It 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2- <br />0 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS r-,4 Yo TYPE OF CASING: 0 STEEL�PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I 0 � /y TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: O Yees )(No (NOTE: Y=IMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Po- Nct'e =/II c"'IJ f- %�,• � • • 1 �. <br />0 OTHER:_G OTHER APPROX. BORING DEPTH �'? p r BOLTED TRAFFIC BOX or Il STOVE PIPE <br />CONDUCTOR CASING PROPOSED Ln (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance , les a Regulations, and all applicable California State Laws. <br />11� <br />Signed x Title/Company:;3 /G7'/W& /%%wwQOv CEGD !/� <br />Print Name /r„fL L�/• peyAds Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (� W -N �(L • LD (� <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />Date <br />nal Inspection By <br />11 <br />'f> <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQLIE§T # <br />INVOICE <br />D l <br />89/ <br />SR# <br />C -57--L WCC -WAIVER_ C-57 Letter of Authorization to sign permit En��a�oc Z 9/30/02 <br />6tZ 1043 - mss✓-6Z3s <br />